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3153 CNS - nat > ic11 schizophrenia > Flashcards

ic11 schizophrenia Flashcards

1
Q

Definition of psychosis

A

Acute episode of disorganised thoughts and speech, hearing things in the absence of stimuli

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2
Q

Definition of Schizophrenia

Onset of Schizophrenia

A

6 months of psychosis

onset: late teenage to adulthood

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3
Q

Causes of Schizophrenia (7 points)

A

Epilepsy

Tumours

CNS infection eg. Meningitidis

Endocrine eg. Hyperthyroidism

Substance abuse eg. alcohol, meth, benzodiazepine withdrawal

Parkinson’s disease medication
Dopamine agonists eg. Levodopa→ induce psychosis

Dementia

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4
Q

What is the diagnosis of Schizophrenia?

A

2 of the following, for at least 1 month

(1-4 are +ve symptoms, 5 is -ve)
1) Delusions
Bizarre belief that is fixated, despite evidence of the contrary

2) Hallucinations
Hearing imaginary voices, patient has no control over it
Seeing things eg. shadows
Smelling things
Taste
Touch

3) Disorganised speech
Manifestation of disorganised thoughts

4) Catatonic behavior (either react very little or too disruptive)

5) Negative symptoms
Affective flattening: dont smile, express emotions
Avolition: lack motivation

Cause social or occupational dysfunction

At least 6 months (including prodromal or residual symptoms)

Not due to medical disorder (eg. hyperthyroidism), substance use

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5
Q

Non pharm for Schizophrenia (3 points)

A

Cognitive Behavioural Therapy (CBT)
Used in conjunction with medications and family intervention

Electroconvulsive Therapy (ECT)
Reserved for treatment resistant Schizophrenia

Psychosocial rehab (integrate back into society)

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6
Q

What is the difference between Benzodiazepines and Antipsychotics?

A

Both used to calm patient down

BZD is solely to calm patient down, does not directly help with Schizophrenia. Will put patient to sleep or cause paradoxical excitement in young children and elderly

Antipsychotics can calm patient down without putting patient to sleep and without causing paradoxical excitement

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7
Q

Why do antipsychotics have sustained effect for a few weeks even after stopping

A

Antipsychotics are fat soluble, enter adipose tissue and act as depot to slowly release into blood

But relapse will still occur if withdrawn abruptly, after a few weeks

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8
Q

What is another indication of antipsychotics

A

Major Depressive Disorder
Aripiprazole
Brexpiprazole
Quetiapine XR

ic13 Bipolar disorder

Off label: Insomnia (low doses of Quetiapine)

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9
Q

when are IM injections indicated?

A

when patients are not adherent (either agitated or just not compliant) or dont prefer oral antipsychotic

Agitation -> typically administered smaller doses eg. Haloperidol 2.5mg
VS
Long acting antipsychotics for maintenance therapy eg. Haloperidol 25 - 50mg + formulated for prolonged release eg. decanoate

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10
Q

which LAI requires most frequent administration? what is the frequency?

A

Risperidone Consta requires every 2 weeks (and oral supplementation for first 3 weeks), the rest of LAI are once monthly

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11
Q

What pathway helps with Schizophrenia?

What pathway causes Schizophrenia side effects? (3 points)

A

Efficacy
Mesolimbic pathway (therapeutic effect)
Involved in (+) symptoms eg. emotion, cognition and attention
D2 receptor antagonism → target (+) symptoms
5HT2A antagonism → target (-) symptoms

Side effects
1) Nigrostriatal pathway
D1 and D2 antagonism, but D2 blockade causes less EPSE than D1
Involved in voluntary movement, hence D1D2 blockade will cause involuntary movement eg. acute dystonia, tardive dyskinesia, akathisia

2) Tuberoinfundibular pathway
Regulates prolactin secretion
Side effects caused by D2, D3 receptor antagonism by Amisulpride

3) Mesocortical Tract
Dopamine blockade will result or worsen existing (-) symptoms

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12
Q

Antagonism / agonism of which receptors will result in therapeutic effects?

A

Antagonise D2 and Serotonin 2A, agonise Serotonin 1A
D2 will improve (+) symptoms
HT2A will improve (-) symptoms
5HT1A will reduce anxiety

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13
Q

Antagonising receptors will result in adverse effects?

A

D2, Serotonin 2C, HAM (H1, alpha adrenergic, muscarinic)

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14
Q

Which receptor, when antagonised, will result in both therapeutic and adverse effects

A

D2

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15
Q

General traits of oral antipsychotics and exceptions

A

Short Tmax (1-3hrs)
Fast absorption, Fast onset

Long half life
Hence can combine multiple doses into single dose
Good for sedating antipsychotics eg. FGA, Olanzapine
Single dose can be taken in early evening if night dose causes patient to be tired the next morning
Exception: Quetiapine, Clozapine (QC before combining doses), as may cause seizures, hypotension

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16
Q

Similarity and difference between FGA and SGA in terms of improving symptoms of Schizophrenia

A

FGA and SGA can reduce (+) symptoms due to dopamine blockade
SGA can also reduce (-) symptoms due to 5HT2A serotonin antagonism

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17
Q

Side effects of FGA and SGA

A

FGA: more EPSE and prolactin secretion

“-pines” (SGA): more weight gain, blood sugar, cholesterol

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18
Q

Between Olanzapine (SGA) and Haloperidol (FGA), which is preferred? Why?

A

Olanzapine is preferred, due to weaker D2 antagonism, and hence lesser EPSE than Haloperidol

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19
Q

Which is the most commonly used antipsychotic?

A

Risperidone (due to high potency)

20
Q

What is the treatment algorithm for Schizophrenia?

A

1) Use one FGA or SGA (except Clozapine)
2) Use another FGA or SGA (except Clozapine)
3) Clozapine (3rd line)

21
Q

Why is Clozapine 3rd line?

A

Most effective antipsychotic!
1) Short half life
2) Anticholinergic
3) Risk of agranulocytosis (low neutrophils), cause opportunistic infections
Need to monitor FBC every week for 18 weeks

22
Q

How long should patient take the medication before treatment is ineffective

A

Patient need to be 80% compliant for 2-6 weeks at optimal therapeutic dose before considered ineffective

23
Q

What patient is contraindicated to take antipsychotics?

A

patients with QTc prolongation

24
Q

In acute agitation, what can be offered if patient is cooperative?

What if patient is not cooperative

A

Cooperative, can give oral
Oral Lorazepam 1-2mg
Oral Risperidone 1-2mg

Uncooperative, consider fast acting IM injection
1) IM Lorazepam

2) IM Olanzapine (immediate release) (SGA)
Better than Haloperidol
Lesser D2 antagonism → EPSE (hand tremors, muscle stiffness)

3) IM Haloperidol (FGA)
If patient wakes up with muscle stiffness with Haloperidol, give IM Benztropine (anticholinergic)

4) IM Promethazine

25
Q

Treatment for Catanonia?

A

PO or IM Lorazepam

ECT

26
Q

Side effects of antipsychotics (6 points)

A

1) EPSE
2) Hyperprolactinemia
3) Metabolic
4) Cardiovascular
5) Neuroleptic malignant syndrome
6) Agranulocytosis

27
Q

What is the cause of EPSE?

Which drug most commonly associated with EPSE?

A

Too much D2 antagonism at the nigrostriatal pathway

Haloperidol (FGA)

28
Q

What are some ways to treat EPSE?

A

benztropine (an anticholinergic)
Reduce antipsychotic dose
Switch to SGA from Haloperidol (FGA)

29
Q

4 types of EPSE and treatment

A

1) Dystonia
painful muscle contraction in the neck
Treatment: benztropine

2) Pseudo-parkinsonism
tremors, rigidity
Treatment: benztropine

3) Akathisia
Restlessness
Treatment: use Clonazepam or Propranolol

4) Tardive Dyskinesia
Involuntary movement of jaw, tongue
More common with FGA
Worsened with anticholinergics
Treatment: stop anticholinergics, treat with Valbenazine or Clonazepam

30
Q

When can Benztropine be used / cannot be used?

A

Can: Dystonia, Pseudo-parkinsonism
Cannot: Tardive dyskinesia (anticholinergic will worsen it), Akathisia (anticholinergics ineffective)

31
Q

What EPSE can Clonazepam be used to treat?

A

Akathisia and Tardive Dyskinesia

32
Q

Treatment of Hyperprolactinemia

A

Switch to Aripiprazole

33
Q

What are metabolic side effects, associated with which antipsychotic?

Treatment

A

Weight gain, increase blood sugar, increase cholesterol
Associated with “-pines”

Treatment: lifestyle modification / diet, Metformin, Use lower risk agent eg. Aripiprazole

34
Q

Cardiovascular side effect examples

A

Orthostatic hypotension
QTc prolongation

patients with QTc prolongation contraindicated with Antipsychotics

35
Q

Neuroleptic Malignant Syndrome symptoms

3 ways to get NMS

A

Lead pipe rigidity, muscle stiffness, fever, very high CK

Succinylcholine
Start potent IM antipsychotic
Suddenly stop Levodopa (as good as taking dopamine antagonist)

36
Q

Treatment for NMS (3 points)

A

IV Dantrolene
Oral Dopamine agonist (eg. Amantadine, Bromocriptine)
Switch to SGA

37
Q

Which drug associated with agranulocytosis?

A

Clozapine, Carbamazepine ic13)

need to monitor FBC every week for first 18 weeks

38
Q

Monitoring for antipsychotics (6 points)

A

BMI

Fasting blood sugar

Lipid panel

Blood pressure

EPSE exam

WBC, ANC (for Clozapine)
Weekly for first 18 weeks

39
Q

What antipsychotic should be used for elderly?

A

Avoid a1 blockade (orthostatic hypotension) and anticholinergic drugs (constipation, urinary retention, delirium), avoid long T1/2 drugs

Anticholinergic agents: FGA, Clozapine (SGA)

Use Quetiapine → short half life, is a SGA

40
Q

Clozapine is a substrate of?

A

1A2

41
Q

Which drugs should not be used with Clozapine?

A

Fluvoxamine (SSRI), is a 1A2 inhibitor

Carbamazepine, as itself can cause agranulocytosis also

42
Q

How do dopamine agonists interact with Antipsychotics

A

Cancel out effect of Antipsychotics

Dopamine agonists eg. Levodopa, Bromocriptine, Amantadine
but can be used for NMS

43
Q

Examples of 1A2 inducers (3 points)

A

Rifampicin (TB drug)
Ph Antiepileptics (Phenobarbital, Phenytoin)
Cigarette smoking

44
Q

Examples of 1A2 inhibitors

A

Fluvoxamine
Quinolones
Macrolides

45
Q

Time taken to see effects

A

1st week: agitation
2-4 weeks: paranoia, hallucinations
6-12 weeks: delusions, negative symptoms

46
Q

5 things about Clozapine

A

1) Agranulocytosis
2) Anticholinergic
3) Short half life
4) Most effective in suicidal patients
5) 1A2 substrate

3153 CNS - nat (11 decks)

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